Methods for performing medical procedures within a breast duct

ABSTRACT

Methods for performing medical procedures within the duct of a breast are described. An exemplary embodiment of the invention includes the steps of introducing a guiding member into a breast duct; introducing and positioning a member having an internal lumen in the breast duct; introducing a wash fluid into the breast duct through the internal lumen; removing washings from the breast duct through the internal lumen; and collecting the washings for cytological analysis.

RELATED APPLICATIONS

This application is a continuation-in-part application and claimspriority under 37 CFR 120 to U.S. application Ser. No. 09/153,564 filedSep. 15, 1998 now U.S. Pat. No. 6,455,027, which is acontinuation-in-part application of U.S. application Ser. No.08/931,786, filed Sep. 16, 1997, now U.S. Pat. No. 6,168,779; and thisapplication is a continuation-in-part and claims priority under 37 CFR120 to U.S. application Ser. No. 09/740,561 filed Dec. 19, 2000 nowabandoned which is a continuation application of U.S. application Ser.No. 09/067,661, filed Apr. 28, 1998, now U.S. Pat. No. 6,221,622, thecontents of each of which are incorporated herein by reference.

The invention disclosed in this application was made with governmentsupport under U.S. Army Medical Research Grant Nos. DAMD17-94-J-4281 andDAMD17-96-C-6117. The government may have certain rights in theinvention.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates generally to medical methods and devicesfor accessing body lumens and in particular to methods and apparatus foridentifying ductal orifices in human breasts and accessing the ductsthrough the identified orifices.

Breast cancer is the most common cancer in women, with well over 100,000new cases being diagnosed each year. Even greater numbers of women,however, have symptoms associated with breast diseases, both benign andmalignant, and must undergo further diagnosis and evaluation in order todetermine whether breast cancer exists. To that end, a variety ofdiagnostic techniques have been developed, the most common of which aresurgical techniques including core biopsy and excisional biopsy.Recently, fine needle aspiration (FNA) cytology has been developed whichis less invasive than the surgical techniques, but which is not always asubstitute for surgical biopsy.

A variety of other diagnostic techniques have been proposed for researchpurposes. Of particular interest to the present invention, fluids fromthe breast ducts have been externally collected, analyzed, andcorrelated to some extent with the risk of breast cancer. Such fluidcollection, however, is generally taken from the surface of the nippleand represents the entire ductal structure. Information on the conditionof an individual duct is generally not provided. Information onindividual ducts can be obtained through cannulation and endoscopicexamination, but such examinations have been primarily in women withnipple discharge or for research purposes and have generally notexamined each individual duct in the breast.

Since breast cancer usually arises from a single ductal system andexists in a precancerous state for a number of years, endoscopy in andfluid collection from individual breast ducts holds great diagnosticpromise for the identification of intermediate markers. Much of thepromise, however, cannot be realized until access to each and every ductin a patient's breast can be assured. Presently, ductal access may beobtained by a magnification of the nipple and identification of ductalorifice(s) using conventional medical magnifiers, such as magnificationloupes. While such magnified examination is relatively simple, it cannotbe relied on to identify all orifices. Moreover, the ductal orifices canbe confused with other tissue structures, such as sebaceous glands andsimple keratin-filled caruncles of the nipple. Thus, before ductaltechniques can be further developed for diagnostic, research, or otherpurposes, it will be useful to provide methods and apparatus whichfacilitate identification of ductal orifices to distinguish them fromother orifices, and allow subsequent ductal access in selected and/orall ducts in each breast.

2. Description of the Background At

Publications by the inventors herein relating to breast duct accessinclude Love and Barsky (1996) Lancet 348: 997-999; Love (1992) “Breastduct endoscopy: a pilot study of a potential technique for evaluatingintraductal disease,” presented at 15th Annual San Antonio Breast CancerSymposium, San Antonio, Tex., Abstract 197; Barsky and Love (1996)“Pathological analysis of breast duct endoscoped mastectomies,”Laboratory Investigation, Modem Pathology, Abstract 67. A description ofthe inventors' breast duct access work was presented in Lewis (1997)Biophotonics International, pages 27-28, May/June 1997.

Nipple aspiration and/or the introduction of contrast medium into breastducts prior to imaging are described in Sartorius (1995) Breast CancerRes. Treat. 35: 255-266; Sartorius et al. (1977) “Contrast ductographyfor the recognition and localization of benign and malignant breastlesions: An improved technique,” in: Logan (ed.), Breast Carcinoma, NewYork, Wiley, pp. 281-300; Petrakis (1993) Cancer Epidem. Biomarker Prev.2: 3-10; Petrakis (1993) Epidem. Rev. 15: 188-195; Petralkis (1986)Breast Cancer Res. Treat 8: 7-19; Wrensch et aL (1992) Am. J. Epidem.135: 130-141; Wrensch et al. (1990) Breast Cancer Res. Treat. 15: 39-51;and Wrensch et al. (1989) Cancer Res. 49: 2168-2174. The presence ofabnormal biomarkers in fine needle breast aspirates is described inFabian et al. (1993) Proc. Ann. Meet. Am. Assoc. Cancer Res. 34: A1556.The use of a rigid 1.2 mm ductoscope to identify intraductal papillomasin women with nipple discharge is described in Makita et aL (1991)Breast Cancer Res. Treat. 18: 179-188. The use of a 0.4 mm flexiblescope to investigate nipple discharge is described in Okazaki et aL(1991) Jpn. J. Clin. Oncol. 21: 188-193. The detection of CEA in fluidsobtained by a nipple blot is described in inayama et aL (1996) Cancer78: 1229-1234. Delivery of epithelium-destroying agents to breasts byductal cannulation is described in WO 97/05898.

SUMMARY OF THE INVENTION

The present invention provides improved methods, kits, and otherapparatus for locating breast ducts in the breasts of human femalepatients. In particular, the methods of the present invention permitreliable identification of the orifices within the nipple of a breastwhich lead to each of the multiple ductal networks within the breast. Byreliably identifying each office, all of the ductal networks can belocated and subsequently accessed for diagnostic, risk assessment,therapeutic, research, or other purposes.

In a first aspect of the present invention, a method for locating anorifice of a breast duct comprises labelling ductal cells disposed atthe ductal orifice with a visible or otherwise detectable label. Theorifice may then be located based on the presence of the label at theorifice. Specific and preferred methods for labeling the orifices aredescribed below in connection with a second aspect of the presentinvention. After the orifices have been located, an access device, suchas a catheter or fiberoptic viewing scope, can be introduced through atleast one of the orifices and into the associated breast duct. Themethod may further comprise introducing the same or a different accessdevice through other orifices, often into each of the orifices to permitdiagnosis, treatment, or other evaluation of all of the ductal networksof a breast.

In a second aspect, the present invention comprises a method forlabelling the orifice of a breast duct. The method includes treating anipple to expose tissue in an orifice of each duct. The treated nippleis then exposed to a labelling reagent capable of specifically bindingto a tissue marker characteristic of tissue at the ductal orifice.Binding of the labelling reagent to the tissue results in immobilizationof a label at the orifice, permitting subsequent location of the orificeas described above. The treating step preferably comprises washing thenipple with a kcratinolytic agent, such as 5% to 50% acetic acid (byweight), to remove keratin-containing materials which normally occludethe duct orifice and which could inhibit binding of the labellingreagent to the tissue marker. The tissue marker is typicallycharacteristic of the ductal epithelium and represents either a membraneantigen or a cytoplasmic antigen. It has been found by the inventorsherein that the ductal epithehum extends to within 0.1 mm to 0.2 mm ofthe nipple orifice and is sufficiently exposed to the surface of thenipple to permit labelling according to the methods of the presentinvention. Exemplary markets include cytokeratins, such as cytokeratin8, cytokeratin 18, E cadherin, epithelial membrane antigen (EMA), andthe like. Usually, the labelling reagent comprises a polycloral ormonoclonal antibody or other specific binding substance specific for themarker. The antibody may be directly labelled with a visible label, suchas a fluorescent label, a dye label a chemiluminescent label, or thelike. Alternatively, the labeling reagent may comprise two or morecomponents, typically including a primary antibody which is specific forthe marker and one or more secondary binding substances which bind tothe primary antibody and provide a label optionally a magnified label.For example, the primary antibody may be unlabeled, and a secondarylabelled antibody specific for the primary antibody also be provided. Asa further alternative, the primary antibody can be labelled with biotinor other hapten, and binding of the label provided via avidin, secondaryantibody specific for the hapten, or the like. Numerous specifictechniques for labelling of antigenic tissue markers are well known andreported in the immnocytochemical staining literature.

In a third aspect, a method according to the present invention compriseslabelling cellular material at a ductal orifice with a visible label andsubsequently accessing the duct through the labelled orifice. Thelabeling step usually comprises the method set forth above. Theaccessing step may comprise introducing an access device through atleast one of the labelled orifices, and preferably through all of thelabelled orifices, where the access device may be a catheter, a fiberoptic viewing scope, or the like.

In a fourth aspect of the present invention, a kit for labelling breastduct orifices comprises a labelling reagent or reagents capable ofspecifically labelling a cellular marker at the ductal orifice,instructions setting forth a labelling method as described above, and apackage containing the labelling reagent and the instructions for use.Usually, the kits of the present invention will further include theketatinolytc agent and any other reagents that may be necessary forperforming the method. Instructions for use will set forth the use ofall provided reagents and may further set forth the use of agents whichare available in the laboratory where the assay is to be performed.

In a fifth aspect of the present invention, a kit for accessing a breastduct comprises a labelling reagent capable of specifically labelling aductal orifice and optionally a keratinolyric agent for treating thenipple prior to exposure of the labelling reagent. The kit furthercomprises an access device capable of being inserted through a labelledductal orifice to a ductal lumen, such as a catheter, a fiber opticviewing scope, or the like. The kit still further comprises a packagecontaining the labelling reagent, optionally the keratinolytic agent,and the access device. The accessing kit may further compriseinstructions for use setting forth a method comprising the accessingsteps as described above.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an anterior view of a human female breast, shown in section,and illustrating three of the six to nine ductal networks extendinginwardly from the nipple.

FIG. 2 is an enlarged view of the nipple of FIG. 1 illustrating theorifices leading to each of the three ductal networks.

FIG. 3 is a still further enlarged view of a single orifice illustratingthe distribution of tissue markets from the epithelium to the opening ofthe orifice, where such markers at the opening are available for bindingto labelled antibodies.

FIG. 4 is a schematic illustration of the appearance of a nipple whichhas been labelled with visible markers according to the methods of thepresent invention.

DESCRIPTION OF THE SPECIFIC EMBODIMENTS

The present invention comprises methods for locating, labeling, andaccessing the ductal networks in human female breasts. A typical breastB is illustrated in FIG. 1 and includes a nipple N and from six to nineducts D.

Three ductal networks D₁₋₃ extending inwardly from the nipple N into thebreast tissue are illustrated As best seen in FIG. 2, each ductalnetwork D₁₋₃ begins with an orifice O₁₋₃ which lies at the surface ofthe nipple N and extends inwardly through a ductal sinus S₁₋₃ and theninto a branching network. Each network D comprises a series ofsuccessively smaller lumens which are arranged in complex,three-dimensional patterns. The networks of each duct will overlapwithin the breast tissue but will not be interconnected. The presentinvention relies on identifying and labelling tissue in the orifice O ofeach duct D within the nipple N. Usually, there will be from six to nineorifices which open into a like number of ductal networks. An abrupttransition from the ductal epithelium to the squamous epithelium of theskin is found within about 0.1 mm to 0.2 mm of the nipple surface.Typically, the ductal orifice will be occluded with a conical keratinplug measuring about 0.5 mm to 1 mm in size.

The present invention relies on the specific labelling of tissue markersat the orifice of selected one(s) or all of the ductal network(s). By“specific,” it is meant that the label will be introduced in a mannersuch that it will bind to the orifice region within the nipple but notbind (or will bind to a significantly lesser extent, usually at least10-fold less) to other regions of the nipple. In this way, binding ofthe label to the orifice will be a discernable indication that theorifice is present and available for access to the associated ductalnetwork.

In a particular aspect of the present invention, the tissue marker(s)will be an antigenic or epitopic site characteristic of the epitheliallining of the breast duct. Surprisingly, it has been found that theepithelial lining extends sufficiently far into the orifice region ofthe duct to permit successful labelling using generally conventionalimmunocytochemical labelling reagents and techniques, as described inmore detail below. Exemplary tissue markers include antigens andepitopes defined by the cytokeratins present in the epithelialcytoplasmic lining, such as cytokeratin 8, cytokeratin 18, and bymolecules present in the membrane lining, such as E cadherin, epithelialmembrane antigen (EMA), and the like. Suitable breast epithelial tissuemarkers are described, for example, in Moll et al. (1982) Cell 30:11-19;Gown and Vogel (1984) Am. J. Pathol. 114:309-321; and Johnson (1991)Cancer Metastasis Rev. 10:11-22.

Referring now to FIG. 3, an orifice region O of a ductal network D isillustrated with a plurality of markers M lining the epithelium of theduct and extending to the perimeter of the orifice. Labelled antibodiesA can be used to locate and label those markers M which are near theorifice O. Frequently, it ill be desirable or necessary to wash thenipple with a solution capable of unblocking the orifice to permitbinding of the antibodies or other labelling reagent. For example, theorifice can frequently become plugged with keratin-contain materials,and washing with a keratinolytic solution, such as acetic acid (5% to50% by weight) admixed in a pharmaceutical delivery vehicle, will exposesufficient marker sites at each orifice to enable labelling according tothe methods of the present invention.

The labelled antibodies or other labelling reagents may be formulated asliquid, typically aqueous, solutions in a generally conventional manner.Suitable anti-cytokeratin antibodies may be obtained from commercialsuppliers, with specific antibodies including FITC-anticytokeratin(Becton-Dickenson), CAM 5.2, and the like. The antibodies may be coupledto one member of a signal-producing system capable of generating adetectable visual or other change on the tissue surface, where anelement will be referred to here and after as a “visual label” Suitablesignal-producing systems include fluorescent systems, color-generatingsystems, and luminescent systems. Preferred is use of fluorescentsystems which comprise a single fluorescent label, but other systemswhich comprise two or more components including enzymes, substrates,catalysts, enhancers, and the like, may also be employed. At least onecomponent of the signal-producing system will be attached to theantibody or other specific binding substance which is capable ofdirectly or indirectly binding to the tissue marker. Usually, theantibody will bind directly to the tissue marker, but it will also bepossible to employ primary antibodies which are specific for the tissuemarker and labelled secondary antibodies which introduce the label orcomponent of the signal-producing system. For example, the primaryantibody can be mouse IgG and the labelled secondary antibody can beFITC goat anti-mouse IgG (Zymcd). Such signal-producing systems and theuse on tissue and tissue samples is well described in the medical,scientific, and patent literature relating to immunocytochemicalstaining.

In an exemplary protocol according to the present invention, the nippleis first dekeratinized with 5% to 50% acetic acid to remove keratin andother potentially blocking and contaminating substances from the ductalorifices. A solution of the labelled antibody, preferably an antibodywhich directly binds to a cytokeratin or other epithelial cytoplasmic orsurface membrane marker, such as the antibodies described above, is thenapplied to the nipple surface. The antibody is preferably linked to afluorescent marker, more preferably fluorescein, and thefluorescein-labelled antibody delivered in a buffered aqueous solution.Optionally, controls may be run. For example, labelled antibodies of thesame Ig class as the specific antibody may be exposed to the nipple atthe same dilution. By comparing the results with the specific antibodyand the control antibody, non-specific binding can be discounted.

The labelling reagent will typically be packaged (optionally with thekeratinolytic agent) together with instructions for use in aconventional assay package, such as a box, bottle, tube, pouch, or thelike. The instructions for use may be written out on a separateinstruction sheet or may be partially or fully incorporated onto thepackaging materials.

A second kit according to the present invention will comprise thelabelling reagent (optionally with the keratinolytic agent) in a packageas set forth above. The package will further include an access devicecapable of being introduced through the ductal orifice, such as acatheter, a fiber optic scope, or the like. Suitable catheters and fiberoptic scopes are described in the background art discussed above. Suchkits may further comprise instructions for use (IFU) setting forth anyof the methods described above.

The following experimental descriptions are offered by way ofillustration, not by way of imitation.

EXPERIMENTAL A. Dekeratinizing the Nipple

Acetic acid is mixed with Velvacrol (50% v/w), a pharmaceutical vehiclecomprising an aqueous mixture of petrolatum/mineral oil, acetyl alcohol,sodium laural sulfate, cholesterol, methylparaben, butylparaben, andpropylparaben. To keep the acetic acid in solution, mcthyl cellulose(100 mg) is pre-added to the Velvacrol (5 g). The mixture possesses auniform pasty consistency and is applied to the nipple as an ointment orpaste. The keratinolhtic agent is typically left on the nipple fortwenty-four hours or longer to remove the keratin plugs from the ductalorifices.

B. Labelling of the Ductal Orifice

For cytoplasmic antigens, the ductal epithelium must be solubilized with70% by weight ethanol. For a membrane or surface antigen, thesolubilization step is not necessary. A mouse monoclonal primaryantibody is used as a dilution of 1:5 to 1:100 and maintained on thenipple for one hour at room temperature. After such incubation, thenipple is washed with phosphate buffered saline PBS and a secondaryantibody (fluoresceinated goat anti-mouse antibody) used at a dilutionof from 1:5 to 1:1000 fold at room temperature. After washing with PBS,the nipple may be examined under ultraviolet (UV) light at a wavelengthselected for the particular fluoroclrome being used. A control can thenbe run using an antibody of a similar class, but without specificity forany of the ductal epithelial or other markers which may be present onthe nipple. This method will provide successful labelling of the ductalorifices and permit subsequent cannulation and examination of eachorifice.

C. Ductoscopy

Duct cannulation and exploration can be performed under white (visual)light. One or more ducts are cannulated first with a rigid metalduct-probe (6 Fr Taber-Rothschild Galactography Kit, Manan MedicalProducts Inc., Northbrook, Ill.) dilated to 0.45 mm to 0.5 mm. A guidewire (0.4 mm) is then inserted, and a catheter passed over the guidewire. Physiological saline (0.2 ml to 0.5 ml) is instilled to wash theduct lumen. The washings may be spun down and analyzed cytologically.

The duct lumen is then dried by injecting 0.2 ml to 0.5 ml air. At theend of the final insufflation, the orifice is held shut by pinching theend of the nipple. An endoscope (FVS-3000, M&M Company, Tokyo), which is0.4 mm in outer diameter is then threaded into the duct orifice whiledilation of the duct with air is maintained. After the endoscope isinserted for 5 mm to 10 mm, its position may be confirmed. Thecannulization may then be continued as far distauly as possible. Desireddiagnostic, therapeutic, or other material may then be instilled intothe duct

Alternatively, after cannulation, the duct may be dilated with salineusing a closed system with a burst adapter to allow a better view.

In a particular aspect of the present invention, cells may be removedthrough the cannula (as washings). The collected cells may be processedaccording to standard cytological methods for similar washings, such asbronchial washings and biopsy specimens. The cells may be identifieddirectly or indirectly by histopathological analysis of the duct fromwhich the cells were obtained.

Although the foregoing invention has been described in detail forpurposes of clarity of understanding, it will be obvious that certainmodifications may be practiced within the scope of the appended claims.

1. A method for performing a medical procedure within a breast duct,said method includes the steps of: introducing a guiding member intosaid breast duct; traducing and positioning a member having an internallumen in said breast duct; introducing a wash fluid into said breastduct through said internal lumen; removing washings from said breastduct through said internal lumen; and collecting said washings forcytological analysis.
 2. The method of claim 1 wherein the collectedwashings include cellular material from within said breast duct.
 3. Themethod of claim 1 wherein said wash fluid includes saline.
 4. The methodof claim 1 wherein said member having an internal lumen includes acatheter; and wherein said step of introducing and positioning saidmember having said internal lumen includes a step of passing saidcatheter over said guiding member.
 5. The method of claim 4 wherein saidcatheter is passed over said guiding member after said guiding member ispositioned within said breast duet.
 6. The method of claim 1 whereinsaid guiding member includes a guidewire; and the method furtherincludes the step of dilating said breast duct before said guidewire isinserted in said breast duct.
 7. The method of claim 6 wherein saiddilating step includes the step of cannulating said breast duct.
 8. Themethod of claim 7 wherein said cannulating step includes introducing arigid duct-probe into said breast duct.
 9. The method of claim 1 whereinsaid medical procedure includes the step of performing a ductoscopy. 10.The method of claim 9 wherein said ductoscopy includes the step ofpositioning an endoscope within said duct for viewing the interior ofsaid duct from which said washings are removed.
 11. A method forobtaining cellular material from within a breast duct during a medicalprocedure, said method includes the steps of: introducing a memberhaving an internal lumen within said breast duct; introducing a fluidinto said breast duct; introducing an endoscope within said breast duct;viewing the interior of said breast duct using said endoscope; removingcellular washings from said breast duct, wherein said step of removingsaid cellular washings includes removing said cellular washings throughsaid internal lumen.
 12. The method of claim 11 wherein said methodfurther includes the step of positioning a catheter within said breastduct, and wherein said fluid is introduced into said breast duct throughsaid catheter.
 13. The method of claim 12 wherein said cellular washingsare removed from within said duct through said catheter.
 14. The methodof claim 11 wherein said member having said internal lumen includes adevice that cannulates an opening to said breast duct.
 15. The method ofclaim 14 wherein said device includes a ductal probe.
 16. The method ofclaim 11 wherein said medical procedure includes a ductoscopy.
 17. Amethod for obtaining cellular material from within a breast duct duringa medical procedure, said method includes the steps of: introducing andpositioning a catheter in said breast duct; introducing a wash fluidinto said breast duct through said catheter; removing washings from saidbreast duct through said catheter; collecting said washings forcytological analysis.
 18. The method of claim 17 further including thestep of introducing an optical scope into said breast duct for viewingthe breast duct.
 19. The method of claim 18 wherein said medicalprocedure includes a ductoscopy.